Insight Series

What are the Character Strengths of a Good Doctor?

Dr Demelza Jones Research Fellow Jubilee Centre for Character and Virtues

WHAT ARE THE CHARACTER STRENGTHS OF A GOOD DOCTOR?

DEMELZA JONES JUBILEE CENTRE FOR CHARACTER AND V/ZdhS UNIVERSITY OF BIRMINGHAM

INTRODUCTION : WHY DOES A DOCT OR’ S CHARACTER MATTER? In recent years fictional doctors with unappealing character traits have become a trope of television depictions of medical settings: the eponymous Dr House whose misanthropy extends to both patients and colleagues, Dr Cox of the hospital-set comedy Scrubs whose bitter tirades reduce his subordinates to tears, and the curmudgeonly ‘Doc Martin’, a rural GP whose gruff demeanour perplexes and offends his patients, to give a few examples. But despite their objectionable behaviour, these characters are simultaneously presented as brilliant doctors whose diagnostic wizardry and cool-head in a medical crisis more than makes up for their lack of a pleasing bedside manner. In reality we are less compromising, and while technical knowledge and clinical competency are of course crucial attributes of the good doctor, we are also concerned with doctors’ manner and behaviour – with their character. This dual concern is clearly reflected in the frameworks which govern medical practice and in the guidance issued by doctors’ professional bodies. For example, the British Medical Association (BMA), the doctors’ trade union, defines medical professionalism as a combination of skills and virtues: ‘a set of values, behaviours and relationships that underpins the trust that the public has in doctors’ (BMA 2012: 5). There are over 200,000 registered practicing doctors in Britain (GMC 2013b), but shortcomings amongst a minority can have disastrous consequences for patients’ wellbeing and for public trust in the medical profession. This is illustrated by exceptional but high profile cases of professional failure, such as the unacceptably high death-rate of babies undergoing heart surgery at the Bristol Royal Infirmary, and the organ retention scandal at Alder Hey children’s hospital. The investigations into these scandals highlighted as causal factors not solely a deficit in clinical competency, but in the character and values of the doctors involved (Hall 2001; Kennedy 2001). More recently, the report of the enquiry into Mid-Staffordshire Hospital Trust found that patients were let down by a lack of care, compassion and humanity; that ward staff, including doctors, showed a lack of respect for patients’ dignity and callous indifference to suffering; and that there was a lack of candour in reporting poor standards of care (Francis 2013). To approach the issue of doctors’ characters from an alternative perspective, few would dispute that medicine is a challenging and demanding career entailing a high level of responsibility and, in some specialties, the need to make life or death decisions under extreme pressure. In Britain the proportion of doctors who exhibit above average levels of stress is around 10% higher than amongst the general working population (Firth-Cozens 2003). Furthermore, innovations in clinical technology such as organ transplant and IVF mean that today’s doctors are faced with more complex ethical judgements than their

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predecessors (BMA 2012: 3). A certain strength of character is required if doctors are to negotiate these challenges and demands of their professional life effectively. So what are the character strengths that make a good doctor? Are the medical profession and its major stakeholder – patients and the public - in agreement about what these desirable strengths are? When patients, the profession, and doctors themselves conjure a mental picture of the ‘good doctor’, are they seeing the same, or at least a similar, being? These questions are considered in this report, alongside the results of a survey of final year students at a UK medical school – the doctors of tomorrow – which asked what they thought the most important character strengths of a good doctor are.

THE GOOD DOCTO R THE PR OFESSION ’S VIEW The Hippocratic Oath, written in the 5th century BC, states that benevolence, “I will use treatments for the benefit of justice, compassion, truthfulness and the ill in accordance with my ability and temperance are essential virtues of my judgment, but from what is to their doctors (Sokol 2008). Of course, the harm and injustice I will keep them” medical profession has undergone huge (The Hippocratic Oath) transformations since Hippocrates’ day, not least in the last 200 years with the Medical Act of 1858 signalling the birth of the modern profession in Britain by introducing compulsory standards of training and creating the independent regulatory body - the General Medical Council (GMC) (Moore 2008). More recently, the mid-twentieth century saw the creation of the National Health Service, making doctors subject to budgets and policy frameworks determined by government and, in the case of hospital doctors, becoming state employees (Ham and Alberti 2002). Alongside these structural changes, shifts have occurred in doctors’ expected behaviour and their position within society. Until the mid-twentieth century doctors’ codes of professional conduct drew on texts such as Thomas Percival’s Medical Ethics, first published in 1803, which ‘encouraged a benignly paternalistic way of thinking that reflected contemporary social expectations. Patients were to be protected from information and the burdens of decision-making were doctors’ duties, not patients’ rights’ (BMA 2012: 3). In contrast, a contemporary emphasis on shared decision-making between doctor and patient means that

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an ‘old model’ of medical professionalism ‘characterised by paternalism, emotional disengagement and establishing certainty’, has been replaced by an emphasis on ‘patientcenteredness and collaboration’ (Borgstrom, Cohn and Barcley 2010: 1330). Despite these shifts, some of the virtues espoused by Hippocrates two millennia ‘Be honest and open and act with ago remain relevant today, and are integrity…Never abuse your patients’ echoed in contemporary professional trust in you or the public’s trust in the guidelines. The BMA, the GMC and the profession’ (GMC) Royal College of Physicians (the largest of the Royal Colleges of medicine) find common voice in foregrounding the importance of truthfulness and trustworthiness as virtues which the good doctor should possess. The very first sentence of the GMC’s Good Medical Practice – the core ethical guidance document for doctors practicing in Britain reads: ‘Patients must be able to trust doctors with their lives and health’ (2013a: i). It goes on to instruct doctors to ‘Be honest and open and act with integrity’ and to ‘Never abuse your patients’ trust in you or the public’s trust in the profession’ (i). Good Medical Practice is also clear in its expectations that doctors should treat colleagues, patients and patients’ relatives with respect and consideration (4 & 16), and that they should act fairly (16-19). It goes on to state that doctors must exhibit kindness or compassion by ‘tak[ing] all possible steps to alleviate pain and distress whether or not a cure may be possible’ (8), and should show humility in ‘recognis[ing] and work[ing] within the limits of [their] competence’ (7). Similarly, the BMA’s handbook Medical Ethics Today states that doctors should be ‘kind, caring, respectful of others, honest and compassionate’ (2012: 12), while the organisation’s guidance for those considering a career in medicine highlights ‘the ability to treat patients politely and considerately, and to be honest and trustworthy’ as essential ‘personal attributes’ of the doctor (BMA 2009a: 2). To give a final example, a report on medical professionalism by the Royal College of Physicians highlights ‘courtesy, kindness, understanding, humility, [and] honesty’ as ‘behaviours that strengthen trust’ and are ‘essential to being a good doctor’ (Royal College of Physicians 2005: 15).

PATIENTS’ VIEWS Perhaps the most important stakeholders in the question of what makes a good doctor are patients themselves. The deference historically shown towards doctors by the public has decreased. High profile scandals have established the possibility of the fallible doctor, while

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internet technology has reduced the mystique of medicine as patients are no longer entirely reliant on their doctor for medical advice (Lewis 2006; Moore 2008). In his submission to the Royal College of Physician’s consultation on medical professionalism, Harry Cayton, then National Director for Patients and the Public at the Department of Health, described how patients’ trust in their doctors’ competency and expertise is critical, but that ‘modern patients are increasingly “Modern patients are increasingly concerned about the manner in which they concerned about the manner in which are treated, wanting respect and courtesy they are treated, wanting respect and as well as kindness, good communication courtesy” (Harry Cayton) and the understanding of options’ (Royal College of Physicians 2005: 20). This concern with doctors’ character and behaviour is further demonstrated by data from the GMC, which shows that a lack of respect for patients is amongst the most common cause of complaints against doctors (GMC 2012: 42), while a 2012 survey by the healthcare charity The Patients Association found that over 40% of respondents did not feel that their GP treated them with compassion. The same report highlights patients’ expectations that doctors should be ‘open and frank’ (2012: 14), while a poll of members of the public by the GMC asking ‘what makes a good doctor’, showed that alongside being competent and knowledgeable, being non-judgemental, a good listener, supportive, understanding, kind and approachable were considered as important attributes (GMC 2011).

THE VIEW S OF FIN AL YEAR ST UDENT S AT A BRIT IS H ME DICAL SCHOOL In 2002 the British Medical Journal asked its readership: ‘what makes a good doctor?’ The 102 responses identified more than 70 qualities: ‘Among the usual—compassion, understanding, empathy, honesty, competence, commitment, humanity—were the less predictable: courage, creativity, a sense of justice, respect, optimism, grace’ (Tonks 2002: 715). In the summer of 2013 this question was posed again, this time to final year medical students as part of a major project taking place within the Jubilee Centre for Character and VŝƌƚƵĞs - a pioneering interdisciplinary research centre focussing on character, virtues and values in the interest of human flourishing, based at the University of Birmingham.1 The project, ‘Virtues and Values in the Professions’, examines the place of values and character in training and professional practice in medicine, teaching and law. 1

For more on the work of the Jubilee Centre for Character and VŝƌƚƵĞs, see www.jubileecentre.ac.uk.

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THE SAMPL E The question, ‘what are the most important character strengths of a good doctor’ was asked of final year students at a large British medical school as part of an online survey designed to assess participants’ views around character and values in the medical profession. These final year medical students, with a mean age of 23.5, had already gained clinical experience through placements and workplace-based elective studies throughout their course, and were about to graduate and embark on their Foundation Year One programme of full-time work in a clinical setting as provisionally registered doctors. The sample of 100 students whose views are considered in this report is broadly reflective of the demographic characteristics of accepted applicants to British medical schools. The breakdown of the sample by ethnic group broadly aligns with that seen in British medical school admissions overall (BMA 2009b: 43), and reflects figures collated by the Independent Schools Council, which show that around 30% of students studying medicine and dentistry in Britain attended independent schools (Shepherd 2011). However, the sample contains a higher percentage of female students than found in the national picture of medical school admissions – 68%, as compared to 56% (BMA 2009b: 61).

Figure 1: Breakdown of sample and accepted applicants to UK medical schools (2008) by ethnic group 80 70 60 50 40

Sample of 100 final year medical students

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Accepted applicants to UK medical schools (BMA 2009b)

20 10 0

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Figure 2: Breakdown of sample and accepted applicants to UK medicine and dentistry schools (2011) by type of school attended 80 70 60 50 40 30 20 10 0

Sample of 100 final year medical students Accepted applicants to UK medical and dentistry schools (Shepherd 2011) State funded

Independent/private

Figure 3: Breakdown of sample and accepted applicants to UK medical schools (2008) by gender 80 70 60 50 40 30 20 10 0

Sample of 100 final year medical students Accepted applicants to UK medical schools (BMA 2009b)

Female

Male

THE VIEWS OF FIN AL YEAR MED ICA L STUDENTS These final year medical students were presented with a list of twenty-four character strengths, and were asked to select and rank the six that they thought it most important an individual possess in order to be a good doctor. The character strengths from which the students were able to choose were taken from the Values in Action (VIA) classification devised by Christopher Peterson and Martin Seligman - US-based psychologists. This list of twenty-four strengths draws on the literatures of world religions and philosophical traditions, and has been shown through empirical research to satisfy criterion such as crosscultural recognition (Peterson and Park 2009: 27). The twenty-four individual strengths may

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be grouped into six ‘core virtues’ – wisdom, courage, humanity, justice, temperance and transcendence (27).

Figure 4: The VIA's six 'core virtues' and their component twenty-four character strengths

We first turn our attention to the frequency with which the students selected a particular character strength as important for a good doctor to possess; that is, how many times a character strength appeared anywhere in a respondent’s selection of six character strengths, regardless of its ranking position. A broad range of character strengths were considered important by the final year students, with twenty-one of the twenty-four available character strengths being selected by at least one survey respondent. Only three character strengths were not selected by any respondents: appreciation of beauty/excellence (abbreviated to ‘appreciation’ in the above diagram and below charts), gratitude, and zest. This breadth reflects the findings of the aforementioned survey conducted by the British Medical Journal ten years ago, where respondents listed over seventy qualities of a good doctor (Tonks 2002: 715).

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However, as shown in Figure 5, there are clear front-runners amongst the students’ selections - character strengths which were selected with a much greater frequency than others. Honesty appears with the greatest frequency, being selected by 89 of the 100 respondents, while teamwork comes a close second with 85 selections. Seven further character strengths were selected by more than a third of respondents: in order of frequency; kindness (61 selections), leadership (58) judgement (56), perseverance (46), love of learning (37), fairness (36), and social intelligence (31). So, as per the VIA classification, the ‘core virtues’ of courage, justice, humanity and wisdom are selected by more than a third of respondents, while strengths comprising the remaining two ‘core virtues’ of temperance and transcendence appear with lesser frequency.

Figure 5: Frequency of character strength selection by final year medical students

Appreciation Bravery Creativity Curiosity Fairness Forgiveness Gratitude Honesty Hope Humour Judgement Kindness Leadership Love Love of learning Modesty Perseverence Perspective Prudence Self-regulation Social intelligence Sprituality Teamwork Zest 0

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As mentioned above, students were not only asked to select six character strengths, but to rank their six selections in order of importance. Retaining our attention on the nine character strengths which were selected by more than a third of respondents, Figure 6 shows the ranking of each within respondents’ top six: in other words, the number of respondents who ranked that character strength the most important for a good doctor to possess, the second most important, and so on. Figure 6: Ranking of character strengths by final year medical students

Honesty

Teamwork

Kindness 1st

Leadership

2nd 3rd

Judgement

4th 5th

Perseverence

6th Love of learning

Fairness

Social intelligence 0

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Considering the data in this way further reveals the degree of importance attached to these character strengths by survey respondents. The position of honesty as the leading character strength is consolidated, as it not only receives the highest frequency of selections, but is ranked as the most important character strength for a good doctor to possess more than any other strength within the top nine (or overall). More than half of the students who selected honesty allocated it the top spot in their ranking, while a further 21% awarded it

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second place. The second and third highest scoring character strengths in terms of frequency, teamwork and kindness, show a much more even distribution in terms of ranking, while others, such as perseverance, love of learning, and social intelligence are weighted towards the lower end of the ranking scale, meaning that while they were selected frequently by respondents, they were considered less important than other character strengths that those respondents selected. As an optional follow-up question within the survey, the students were asked to describe a doctor they had encountered (either as a patient or during their training) who they felt exhibited character strengths in their work. Among the twenty-six students who answered this question, the frequency with which particular character strengths were mentioned mirrored the results of the previous selection and ranking exercise (although, of course, this may have been influenced by that exercise). Honesty, teamwork and kindness/care appeared repeatedly in students’ descriptions of these doctors. To give a few examples, one student described a GP who ‘showed a great deal of kindness when dealing with his patients’, another wrote about a consultant who ‘was always clear and straight and very honest to patients about their outcome and treatment options’, while a third recounted: ‘I worked with a doctor who made an effort to ask the name of every member of staff that he spoke to, regardless of their role, in an effort to maintain a good team atmosphere’.

CONCLUSION S At its outset this report asked, ‘when patients, the profession, and doctors themselves conjure a When patients, the profession, mental picture of the ‘good doctor’, are they and doctors themselves conjure a seeing the same, or at least a similar, being?’ The mental picture of the ‘good answer, it would seem, is yes. The emphasis doctor’, are they seeing the same, placed on honesty or integrity, and compassion or at least a similar, being? in the guidance issued by medical professional bodies is echoed in patients’ expectations that doctors should treat them with care and compassion, and be ‘open and frank’ (The Patients Association 2012: 14). This is in turn mirrored in the views of the 100 final year medical students whose survey responses are presented in this report, who identify honesty as the most important character strength a good doctor should possess, with kindness (analogous within the VIA framework to care or compassion) being the third most frequently selected. A deviation between these different stakeholders’ views occurs around the character strengths of teamwork and leadership. These are identified as important in the professional

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literature, and rank highly in the final year students’ selections (respectively second and fourth in terms of frequency), yet are not strongly apparent in the literature around patients’ and the public’s expectations of the good doctor. Perhaps this can be explained by an understandable focus by patients and the public on the character strengths which may emerge in their own direct interactions with doctors, and a comparable lack of attention to doctors’ interaction with other doctors and healthcare staff, which, while crucial to patient care, is sometimes hidden from patients’ direct observation. Research into medical professionalism by the health charity the King’s Fund states that ‘members of the public, professionals, politicians, patients, policy-makers and journalists seem to differ in their views of what doctors should do and how they should behave’ (Rosen and Dewer 2004: 18). While this report has focused only on the views of patients/the public, the medical professional bodies, and newly qualified doctors themselves, its findings may suggest that the divergence the King’s Fund identifies lies not with expectations of what the good doctor is ‘like’ in terms of character strengths and attributes, but how these strengths are enacted (or are able to be enacted) in practice. This is an issue that is currently under scrutiny within the Jubilee Centre for Character and Values’ project on Virtues and Values in the Professions, which through interviews with trainee medics and established doctors seeks to identify those factors which enable or constrain doctors from fulfilling their own and the public’s ideal of the ‘good doctor’, and enacting those character strengths which they view as important, and which, it seems, closely align with the expectations of the profession, patients and the public.

ACKNOWLEDGEME NT This report was made possible through the support of a grant from the John Templeton Foundation. The opinions expressed in this report are those of the author and do not necessarily reflect the views of the John Templeton Foundation.

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REFERENCES BMA (2012) Medical Ethics Today (3rd Edn.) London: BMA BMA (2009a) Becoming a Doctor: In a Nutshell. London: BMA BMA (2009b) Equality and Diversity in UK Medical Schools. London: BMA Borgstrom, E., Cohn, S., & Barclay, S. (2010) Medical professionalism: Conflicting values for tomorrow's doctors. Journal of General Internal Medicine, 25(12): 1330-1336 Firth-Cozens, J (2003) Doctors, their wellbeing, and their stress. BMJ, 326(7391): 670-1 GMC (2013a) Good Medical Practice. London: GMC GMC (2013b) List of Registered Medical Practitioners – Statistics. General Medical Council. http://www.gmc-uk.org/doctors/register/search_stats.asp (17/05/2013) GMC (2012) The State of Medical Education and Practice in the UK. London: GMC GMC (2011) What Makes a Good Doctor? General Medical Council. http://www.youtube.com/watch?v=6_DFcRiK0ZM (17/05/2013) Francis, R (2013). The Mid Staffordshire Foundation Trust Enquiry. London: The Stationary Office Ham, C and Alberti, K. G. M. M (2002) The medical profession, the public and the government, BMJ, 324(7341): 838-42 Hall, D (2001). Reflecting on Redfern: What can we learn from the Alder Hey story? Archives of Disease in Childhood, 84(6): 455-6 Kennedy, I. (2001). The Report of the Public Inquiry into Children’s Heart Surgery at the Bristol Royal Infirmary 1984-1995: Learning from Bristol. London: Crown Copyright Lewis, T (2006) Seeking health information on the internet: Lifestyle choice or bad attack of cyberchondria? Media, Culture, Society, 28(4): 521-39 Moore, J (2008) What Sur Luke Fildes’ 1887 painting ‘The Doctor’ can teach us about the practice of medicine today, British Journal of General Practice, 58: 210-13 Peterson, C and Park, N (2009) Classifying and measuring strengths of character, in Snyder, C. R. and Lozez, S. J (eds.) Oxford Handbook of Positive Psychology. Oxford: Oxford University Press Rosen, R and Dewar, S (2004) On Being a Doctor: Redefining Medical Professionalism for Better Patient Care. London: King’s Fund Royal College of Physicians (2005) Doctors in Society: Medical Professionalism in a Changing World. London: Royal College of Physicians Sokol, D (2008) A guide to the Hippocratic Oath. BBC News. Sunday 26th October 2008. http://news.bbc.co.uk/1/hi/7654432.stm (19/02/2012) The Patients Association (2012) Patients and GPs – Partners in Care? The Patients Association: London Tonks, A (2002) What makes a good doctor: Summary of responses. BMJ, 324(7353): 715

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Insight Series The Jubilee Centre for Character and Virtues  Pioneering interdisciplinary research of international standing focussing on character, virtues and values in the interest of human flourishing.  Promoting a moral concept of character in order to explore the importance of virtue for public and professional life.  A leading informant on policy and practice in this area through an extensive range of research and development projects contributing to a renewal of character and values in both individuals and societies.

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